Frequent switchers have lower quality of life, higher suicidality

People with HIV who frequently switched treatment, and even more so patients who stopped treatment, were significantly more likely to be depressed or suicidal, a British study has found. Patients who switched treatment more frequently also had poorer adherence, regardless of whether they switched due to treatment failure or side-effects. The findings were presented earlier this month at the Eighth AIDS Impact Conference in Marseilles, France.

In this UK study, Professor Lorraine Sherr of Royal Free Hospital and University College, London, gave 778 consecutive patients attending five HIV clinics in London and Brighton a questionnaire to examine HIV treatment decisions, treatment satisfaction, switching rates and triggers, stopping, treatment adherence, symptoms, quality of life, risk behaviour and doctor-patient satisfaction.

Quality of Life was measured by the SF-36 questionnaire (a longer version of SF-12), physical pain by the MSAS scale, and adherence, not only to doses taken but to time of dosing and food restrictions, was also measured.

Two-thirds of patients were gay men and two-thirds Caucasian; a quarter were black African and a quarter were women; 10% were heterosexual men.

The questionnaire got a high response rate, with 85% of eligible patients and 77% of all patients completing it.

Twenty-one per cent of patients had not taken antiretroviral therapy (ART); 22% (28% of patients who had taken anti-HIV therapy) were on their first ART regimen, 18% (23% of ART takers) had switched regimens once, 26% (33% of ART takers) had switched more than once, and 13% (16% of ART takers) had stopped treatment.

Patients could choose more than one reason for switching on the questionnaire, and indeed the average number of reasons cited was 2.76. The most common reasons for switching were poor viral load response and ‘future concerns’ about side-effects (about 25% each), body shape changes, resistance and sickness/nausea (about 20% each).

Patients were in general happy that they had switched. A total of 96% said it was a ‘wise’ decision and 90% said it was a shared decision with their doctor, though 63% said the idea of switching had been initiated by their doctor and only 21% by themselves. Nineteen per cent, however, worried that their decision had been ‘risky’.

Gay men were more likely to be multiple switchers and heterosexual females were more likely to be treatment-naive. Heterosexual males were less likely to be treatment-naive, and more frequently non-switchers. Multiple switchers were more likely to be white, UK-born or had lived in the UK for over five years.

The most striking finding was probably the difference in suicidal thoughts. Thirty-one per cent of all patients reported suicidal ideation, with 43% of patients who had stopped ART reporting this, 35% of patients who had switched once, 30% of multiple switchers and 27% on their first regimen.

Patients who were treatment-naive or on their first or second regimen reported a lower symptom burden and higher quality of life. Multiple switchers reported a higher physical symptom burden (p=0.003) more psychological symptoms (p=0.03) and a higher global distress score (p=0.002).

The other striking finding was that ,despite having had to switch possibly numerous times, multiple switchers still reported considerably lower adherence that non-switchers or first-switchers.

Seventy-eight per cent of patients on antiretroviral therapy had over 95% adherence but only 55% of multiple switchers. This was when adherence was calculated simply in terms of doses per day; however, only 41% of patients on ART managed to take more than 95% of their doses on time and in accordance with food restrictions. Asked whether, with modern ART regimens, this really mattered, Sherr reported that a high proportion of patients were still on “old fashioned, rigid” regimens.